48yr old female, ICU Bed 4


48yr old female , daily wage labourer, stopped working now,  has two male children, came to casualty with cheif complaints of
1. FEVER ASSOCIATED WITH CHILLS AND RIGORS since 3days.
Associated with JAUNDICE since 3days.

No H/O pain abdomen, pedal edema, vomitings.
 SPLENOMEGALY+.

3yrs back , came with cheif complaint of 
MASS PER ABDOMEN- MASSIVE SPLENOMEGALY.

NOT A K/C/O DM,HTN,ASTHMA, TB, EPILEPSY.
No significant drug history.
No significant family history.

PERSONAL HISTORY:
Takes mixed diet.
Normal appetite
Regular bowel and bladder movements
No known allergies.
No addictions.

O/E:
Pt is c/c/c
PALLOR: +
ICTERUS:+
NO cyanosis, clubbing, lymphadenopathy, edema.
No malnutrition.
No dehydration.

VITALS:
Afebrile temperature
PR: 100BPM
RR:18CPM
BP:100/80MMHG
SPO2:100%
GRBS:. 86 MG/DL.
CVS: S1S2+
RS: BAE+
PER ABDOMEN:
  SPLENOMEGALY+
  SPLEEN IS PALPABLE.
BS+
CNS: NAD.

INVESTIGATIONS:

HEMOGRAM:
HB: 9.1
TLC:1000
N:50%
L:50%
PLT: 50,000

RBS: 149 MG/DL

BLOOD UREA: 17MG/DL

LFT:.
TB:1.65
DB:0.60
SGOT:27
SGPT:10
ALP:92
TP:6.4
ALB:3.6
A/G:1.30

SERUM CREATININE: 0.8

SERUM ELECTROLYTES:
Na:140.
K:3.5
Cl:2.5

URIC ACID: 2.5

PROVISIONAL DIAGNOSIS:

SLE FLARE-UP/INFECTION SECONDARY TO DISCONTINUATION OF MEDICATION.

K/C/O SLE WITH PORTAL VEIN THROMBOSIS.

PLAN OF CARE:
1 . T. PROPRONOLOL 20MG H/S
2. T. HCQ 200MG H/S
3. T.PREDNISOLONE 5MG /OD
4. T.FOLATE 5MG /OD
5. T.PAN 40MG /OD
6. T.SHELCAL 500MG /OD
7.T. AUGMENTIN 625MG /BD.




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